Characteristics and Predictors of Fluctuating Attention-Deficit/Hyperactivity Disorder in the Multimodal Treatment of ADHD (MTA) Study

Margaret H. Sibley, PhD; Traci M. Kennedy, PhD; James M. Swanson, PhD; L. Eugene Arnold, MD; Peter S. Jensen, MD; Lily T. Hechtman, MD; Brooke S. G. Molina, PhD; Andrea Howard, PhD; Laurence Greenhill, MD; Andrea Chronis-Tuscano, PhD; John T. Mitchell, PhD; Jeffrey H. Newcorn, MD; Luis A. Rohde, MD, PhD; Stephen P. Hinshaw, PhD; MTA Cooperative Group

J Clin Psychiatry 2024;85(4):24m15395

Abstract

Objectives: Recent studies report a fluctuating course of attention-deficit/ hyperactivity disorder (ADHD) across development characterized by intermittent periods of remission and recurrence. In the Multimodal Treatment of ADHD (MTA) study, we investigated fluctuating ADHD including clinical expression over time, childhood predictors, and between- and within-person associations with factors hypothesized as relevant to remission and recurrence.

Methods: Children with DSM-5 ADHD, combined type (N = 483), participating in the MTA adult follow-up were assessed 9 times from baseline (mean age = 8.46) to 16-year follow-up (mean age = 25.12). The fluctuating subgroup (63.8% of sample) was compared to other MTA subgroups on variables of interest over time.

Results: The fluctuating subgroup experienced multiple fluctuations over 16 years (mean = 3.58, SD = 1.36) with a 6- to 7-symptom within-person difference between peaks and troughs. Remission periods typically first occurred in adolescence and were associated with higher environmental demands (both between- and within-person), particularly at younger ages. Compared to other groups, the fluctuating subgroup demonstrated moderate clinical severity. In contrast, the stable persistent group (10.8%) was specifically associated with early and lasting risk for mood disorders, substance use problems in adolescence/ young adulthood, low medication utilization, and poorer response to childhood treatment. Protective factors were detected in the recovery group (9.1%; very low parental psychopathology) and the partial remission group (15.6%; higher rates of comorbid anxiety).

Conclusions: In the absence of specific risk or protective factors, individuals with ADHD demonstrated meaningful within-individual fluctuations across development. Clinicians should communicate this expectation and monitor fluctuations to trigger as-needed return to care. During remission periods, individuals with ADHD successfully manage increased demands and responsibilities.

Trial Registration: ClinicalTrials.gov identifier: NCT00000388

J Clin Psychiatry 2024;85(4):24m15395

Author affiliations are listed at the end of this article.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Buy PDF for $40

Please sign in or purchase this PDF for $40.

References (42)

Sibley MH, Mitchell JT, Becker SP. Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry. 2016;3(12):1157–1165. PubMed CrossRef
Ahlberg R, Du Rietz E, Ahnemark E, et al. Real-life instability in ADHD from young to middle adulthood: a nationwide register-based study of social and occupational problems. BMC psychiatry. 2023;23(1):1–8. PubMed
Grevet EH, Bandeira CE, Vitola ES, et al. The course of attention-deficit/hyperactivity disorder through midlife. Eur Arch Psychiatry Clin Neurosci. 2022;9:1–2.
Norman LJ, Price J, Ahn K, et al. Longitudinal trajectories of childhood and adolescent attention deficit hyperactivity disorder diagnoses in three cohorts. EClinicalMedicine. 2023;60:102021. PubMed CrossRef
Sibley MH, Arnold LE, Swanson JM, et al. Variable patterns of remission from ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. 2022;179(2):142–151. PubMed CrossRef
Van Meter AR, Sibley MH, Vandana P, et al. The stability and persistence of symptoms in childhood-onset ADHD. European Child & Adolescent Psychiatry;2023:1–8.
Nordgaard J, Nielsen KM, Rasmussen AR, et al. Psychiatric comorbidity: a concept in need of a theory. Psychol Med. 2023;53:5902–5908. PubMed CrossRef
Barkley RA, Murphy KR, Fischer M. ADHD in Adults: What the Science Says. Guilford Press; 2010.
Biederman J, Petty CR, Clarke A, et al. Predictors of persistent ADHD: an 11-year follow-up study. J Psychiatr Res. 2011;45(2):150–155. PubMed CrossRef
Roy A, Hechtman L, Arnold LE, et al. Childhood factors affecting persistence and desistence of attention-deficit/hyperactivity disorder symptoms in adulthood: results from the MTA. J Am Acad Child Adolesc Psychiatry. 2016;55(11):937–944.e4. PubMed CrossRef
Kofler MJ, Raiker JS, Sarver DE, et al. Is hyperactivity ubiquitous in ADHD or dependent on environmental demands? Evidence from meta-analysis. Clin Psychol Rev. 2016;46:12–24. PubMed CrossRef
Turgay A, Goodman DW, Asherson P, et al. Lifespan persistence of ADHD: the life transition model and its application. J Clin Psychiatry. 2012;73(2):192–201. PubMed CrossRef
Lasky AK, Weisner TS, Jensen PS, et al. ADHD in context: young adults’ reports of the impact of occupational environment on the manifestation of ADHD. Soc Sci Med. 2016;161:160–168. PubMed CrossRef
Meaux JB, Green A, Broussard L. ADHD in the college student: a block in the road. J Psychiatr Ment Health Nurs. 2009;16(3):248–256. PubMed CrossRef
Hechtman L, Swanson JM, Sibley MH, et al. Functional adult outcomes 16 years after childhood diagnosis of attention-deficit/hyperactivity disorder: MTA results. J Am Acad Child Adolesc Psychiatry. 2016;55(11):945–952.e2. PubMed CrossRef
MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086. PubMed CrossRef
Jensen PS, Arnold LE, Swanson JM, et al. 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry. 2007;46(8):989–1002. PubMed CrossRef
Molina BSG, Flory K, Hinshaw SP, et al. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1028–1040. PubMed CrossRef
Molina BSG, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484–500. PubMed CrossRef
Molina BSG, Hinshaw SP, Arnold LE, et al. Adolescent substance use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52(3):250–263. PubMed CrossRef
Swanson JM. School-based Assessments and Interventions for ADD Students. KC Publications; 1992.
Swanson JM, Schuck S, Porter MM, et al. Categorical and dimensional definitions and evaluations of symptoms of ADHD: history of the SNAP and the SWAN rating scales. Int J Educ Psychol Assess. 2012;10(1):51–70. PubMed
Conners CK, Erhardt D, Sparrow E. Conner’s Adult ADHD Rating Scales: CAARS. MHS; 1999.
Swanson JM, Kraemer HC, Hinshaw SP, et al. Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry. 2001;40(2):168–179. PubMed CrossRef
Bird HR, Shaffer D, Fisher P, et al. The Columbia Impairment Scale (CIS): pilot findings on a measure of global impairment for children and adolescents. Int J Meth Psy Res. 1993;3(3):167–176.
Bird HR, Andrews H, Schwab-Stone M, et al. Global measures of impairment for epidemiologic and clinical use with children and adolescents. Int J Meth Psy Res. 1996;6(4):295–307.
Fabiano GA, Pelham WE Jr., Waschbusch DA, et al. A practical measure of impairment: psychometric properties of the Impairment Rating Scale in samples of children with attention deficit hyperactivity disorder and two school-based samples. J Clin Child Adolesc Psychol. 2006;35(4):369–385. PubMed CrossRef
Shaffer D, Fisher P, Lucas CP, et al. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39:28–38. PubMed CrossRef
Jensen PS, Hoagwood KE, Roper M, et al. The Services for Children and Adolescents–Parent Interview: development and performance characteristics. J Am Acad Child Adolesc Psychiatry. 2004;43(11):1334–1344. PubMed CrossRef
Swanson JM, Arnold LE, Molina BSG, et al. Young adult outcomes in the follow-up of the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry. 2017;58(6):663–678. PubMed CrossRef
Swanson JM, Hinshaw SP, Arnold LE, et al. Secondary evaluations of MTA 36- month outcomes: propensity score and growth mixture model analyses. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1003–1014. PubMed CrossRef
Leffa DT, Caye A, Belangero SI, et al. The synergistic effect of genetic and environmental factors in the development of attention-deficit/hyperactivity disorder symptoms in children and adolescents. Dev Psychopathol. 2023;24:1–11.
Rutter M, Cox A, Tupling C, et al. Attainment and adjustment in two geographical areas: I—the prevalence of psychiatric disorder. Br J Psychiatry. 1975;126(6):493–509. PubMed CrossRef
Halperin JM, Wolf LE, Pascualvaca DM, et al. Differential assessment of attention and impulsivity in children. J Am Acad Child Adolesc Psychiatry. 1988;27(3):326–329. PubMed CrossRef
Hinshaw SP, Owens EB, Wells KC, et al. Family processes and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment. J Abnorm Child Psychol. 2000;28(6):555–568. PubMed CrossRef
Benjamini Y, Hochberg Y. Multiple hypotheses testing with weights. Scand J Statistics. 1997;24(3):407–418.
Thorndike EL. Measurement of intelligence. Psychol Rev. 1924;31(3):219–252.
Molenaar PC. A manifesto on psychology as idiographic science: bringing the person back into scientific psychology, this time forever. Measurement. 2004;2(4):201–218.
Curran PJ, Bauer DJ. The disaggregation of within-person and between person effects in longitudinal models of change. Annu Rev Psychol. 2011;62:583–619. PubMed CrossRef
Wang LP, Maxwell SE. On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychol Methods. 2015;20(1):63–83. PubMed CrossRef
Arnold LE, Roy A, Taylor E, et al. Predictive utility of childhood diagnosis of ICD-10 hyperkinetic disorder: adult outcomes in the MTA and effect of comorbidity. Eur Child Adolesc Psychiatry. 2019;28(4):557–570. PubMed CrossRef
March JS, Swanson JM, Arnold LE, et al. Anxiety as a predictor and outcome variable in the Multimodal Treatment Study of Children with ADHD (MTA). J Abnorm Child Psychol. 2000;28(6):527–541. PubMed CrossRef