Research Recap with Skye: Multitreatment of ADHD

0:05Welcome to Hacking Your ADHD. I'm your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I'm joined by Skye Waterson for our research recap series. In this series, we take a look at a single research paper, or in today's case, multiple papers, and dive into what the papers say, how it was conducted, and try and find any practical takeaways. In this episode, the first paper we're discussing is called "The MTA at Eight Years: Prospective Follow-Up of Children Treated for Combined-Type ADHD in a Multisite Study." And so this is about the MTA, the Multitreatment Study of Children with ADHD, which was the largest, most expensive, and most influential study conducted on ADHD treatment that was published in 1999.

0:54And so we'll d- get into a few more details about what that paper is in a bit, but it had a huge impact on how we view ADHD, especially in highlighting how to think of, this shift into thinking of ADHD as a chronic condition that requires, a sustained management rather than just something that you cure. dive in and talk about what's going on in this eight-year follow-up study. Yeah. Yeah, 100%. Yeah, it was really interesting, 'cause obviously they're doing, multiple methods of treatment, which I think was the most, the, obviously the thing that made this study the most interesting.

1:27So they had different kinds. They had, they had systematic medication management. They had, multi-component behavioral therapy, then they had a combination, and then they had the usual community care. So they were looking at these four different methods to see the effect that they had on these children over time, which, was that the first time that that's ever happened? Yeah, I think so. And it was definitely, I mean, as I said in the intro, it's was-- this is a huge study that they did.

1:58It was with what? Uh, almost 580 children, and, uh, the time span of ha- looking at things at eight years is incredible Yeah, it's a longitudinal study where they actually, I don't know if it was randomized, but they definitely, divided them into different groups and, and, and did things like that, which was pretty awesome. And also shout out to the parents for letting them do this. Yeah. Um, and yeah, and then it's also, uh, we're looking at kids that are, were ages like seven to nine.

2:27And so this is really getting a, full spectrum of, uh, childhood, 'cause if you're nine at the, uh, start of the study, you're 17 at the end, and that's such a huge change in life, um, which we are gonna get into as well, What they were really wanting to look at this study is how well, uh, treatment worked over time, like what interventions did, uh, on a longer timescale rather than just being like, "Hey, we did a, you know, six-week study and the people did great." But they're like, "Okay, but how did they do way in the future?"

3:04Yeah, exactly, exactly. So they were, reassessed at the 14-month treatment phase, at the 24 and 36 month, and then again at six and eight years, uh, post-randomization with the treatment phase. They actually did have very, very high participation rates as well, which you always gotta check when you have a study like this. So they had 97, 93, 84, 78, and 75, which is, which is really good uh, it is really interesting. And so I, I think this is also important to mention so that this study, the initial portion of the study was fairly well regulated at 14 months with all these check-ins, and then it was kind of like more of a natural experiment as it went on out to the eight-year mark Yeah.

3:51Yeah, it's pretty hard to do that. But they also had a comparison group. So they had a local normative comparison group that was recruited at 24 months that was made specifically to reflect the local populations from which the sample was drawn. So when we talk about comparisons, which we'll get to in a second, that's where they were coming. But weirdly, they said children were not excluded due to ADHD, and so that is a little bit of a factor Well, I can definitely see why they would do that in that they're like, "Hey, we just want…" If you were a randomly selected person from this group, it's going to include people that have ADHD, and so that they didn't want to, skew either way.

4:31Um, I could see the argument for excluding them, but I can also be like, "Oh yeah, it makes sense to have them as a part of the larger whole of what's going on." Yeah. And also I, I imagine, again, this is a big study. They're not just looking at, they're looking at so many different factors that they wanna take into account Yeah, absolutely. I think, I mean, one of the big things was… So like, yeah, absolutely the, their initial, uh, intervention had great effects on reducing ADHD symptoms, although they were still behind the, uh, localized group.

5:10Mm-hmm. Uh, but when we go out toward the eight-year mark, the intervention disappears That was crazy. I have a big exclamation point next to it on my, on my notes because that, I think that was the most interesting thing to me, and then the medication use over time was also really interesting Yeah, 'cause by, uh, year eight they only had, a third of the group still on any form of medication, Mm-hmm. which is a huge drop-off. Um, and it is very understandable when you realize we're talking about teenagers.

5:56Uh, Yeah but it is also something that is oh, that's going to have What I thought was more interesting though was that even the medicated group still did not have the same intervention level as, uh, the, the initial 14 months did Well, that was the thing, and I think, uh, you know, obviously I'm… and I wanna say this upfront, I'm always very supportive of everyone using whatever method works for them to support their ADHD. But it did make me wonder a little bit of what the causation, um, crossover was there.

6:32Because like you described it as like the medication group stopped taking medication because, they were teenagers. And, and sure, that is true, but if you look at the people who did take the medication, they were not exper- like, they initially were experiencing those really positive results compared to their peers. But then they didn't over time. Like, the treatment was about the same. And so, Mm-hmm. you know, obviously we wouldn't usually be saying these things, but this is a really big study.

6:59There's a possibility that they kind of knew that, and that was part of the reason why they decided not to take the medication over a long period of time Yeah, it's, uh, really interesting to further data on… 'Cause we, we don't have any information from them on why they stopped taking the medication, which, um, there, in previous studies that we've looked at that have dis- discussed why people stop using medication, there are a lot of reasons that people might stop taking medication, um, with, uh, social pressure and, you know, side effects, not feeling like it's working well enough, The doctor says you should stop taking it on the holiday periods, and then you don't pick it up again?

7:43Yeah. Or, uh, the cost is a big one too, cause, um… And, uh, I was just thinking, I don't, I need to look up the, when some of the, our more, uh, modern medications came out, like Adderall and all that, and what was available to them in 1999 versus, the last 15 or 20 years Mm. Yeah, that's a good point. It did remind me though, this paper did remind me of that paper about medication adherence, um, where they did go into all the reasons why people didn't take it.

8:15Um, and yeah, it, it, it felt like this was a- as, as it, you'd expect it to be, a really big bird's-eye view of that conversation Yeah. So I think one of the big takeaways that we want, I want people to hear from this because they're, it sounds a lot like, "Oh, the intervention didn't work. Nobody, everybody went off and stopped taking medication, and it was, everything was the same." And it was like, well, the big thing that we're taking, should be taking away is that you need to keep treating your ADHD if you want to keep seeing symptom reduction.

8:50Mm-hmm. If you just simply stop treating it, you're not gonna keep the benefits Yeah. Yeah, so in terms of that though, it is interesting, because they did find that, yeah, all of the different methods were kind of the same. So would you say that's because of the… Would you say, I'm not… I don't wanna put you on the spot here, but what does this mean about the type of treatment that you decide to take? Well, I think one thing that you can take is that if a certain treatment isn't working for you, there are other options for you to try.

9:26You don't have to be like, "This is… I only have this one lane I can go to." Um, I do think, um, when we bring in the other paper, we can also talk a lot, a little bit about the, uh, concept of pills don't teach skills and how that applies here. Um, and I think that… Yeah, actually, how about we bring that other paper in? I think that actually brings in a lot of those points because come on out, stick and paper? All right, so second paper, The Transition to Middle School is Associated With Changes in the Developmental Trajectory of ADHD Symptomatology in Young Adolescents With ADHD.

10:06Oh, that is Well done. I, uh, I sh-, I'm like, hmm, symptomatology is a great word. That's so long. Uh, but yeah, so this is talking, so, uh, to like, this is papers looking at the same MTA data. It runs an algorithm to try and see, talk about kids going into middle school, 'cause they didn't have, the specific data in the MTA study. But it's having this argument that it's not just getting older that's going on, it's a change in life and change in demands.

10:42And I think that is of those things that we have to look at when we're considering this treatment option is, yeah, what are our life demands and how is it changing what we're doing? Mm-hmm. Yeah, 100%. and with, uh, this, yeah, this idea of pills don't teach skills, you need to learn how to manage your ADHD beyond what just currently exists for you Yeah. Yeah, exactly. Exactly. And it was interesting to see, you know, with this conversation, having a look at, at that transitional period of life.

11:18Can you give me a m- take a minute to describe th- this for me? Because from a international perspective, middle school is not as much of a thing. we have, um, we have primary, intermediate, and college, and yeah, intermediate school is a transition, but I feel like American middle school is its own thing. I can actually, I got my emails this week on, uh, what to expect for transferring my elementary school-aged daughter into middle school next year, 'cause we're, gearing up for that.

11:51And so I'm like, "Oh, this is very on note for what I m- know about right now." And a big change for middle school for, uh, kids in the US is that you go from having, a single teacher that has, other teachers come in to do things. So, in elementary school, they'll have, their homeroom teacher, and then, um, they might go to PE or music or, they have, social-emotional or STEM stuff. They'll, they'll have, uh, uh, specialist teachers that come in and help the primary teacher.

12:21But the primary teacher is your main teacher that you get throughout the day. When you go into middle school, you have different classes, and each class will have a different teacher. So you have, go to your English teacher, your math teacher, your history teacher, and all of that. And so it's, um, instead of having a single adult that you're working with, you're working with a bunch, and you're doing, uh, a lot more, uh, mental organization of like, "Okay, now I have to go to…"

12:47'Cause you, you're, don't have the same schedule with all your same friends the entire day Yeah. Okay. This makes sense. This remind… This is sort of the transition to intermediate school, and it is true. I- that was when my ADHD started to become very obvious looking back, because I had different books and different classes, and I remember writing an essay in one notebook, putting, you know, printing it out, putting it in the wrong notebook, not having it in the right class, and getting in trouble for, losing my paper all the time, um, because that's what we were doing Yeah, and like having to make sure you have all the right books with you, uh, having to, yeah, being like, "Oh, I have this homework due in this class and this homework due in this class," and like it's a lot more of a, uh, mental transition.

13:36And then, uh, while not mentioned specifically in this paper, I was discussing this with my wife, you also have just, uh… This is when you're getting hit with puberty and you have a lot of emotional changes and social changes going along as well Yeah. And as I remember, there is research to indicate that, um, for, for a woman especially going through puberty is a factor. It can be a, a, a factor with ADHD as well Yeah. So yeah, so just to mention though, for this paper specifically, they're just looking at having multiple teachers, harder assignments, and more independence.

14:14That's, which I was… That felt like a kind of a problem to me, but I also was like, "Oh, well, if they're grabbing this from the MTA, there's a reason that there's no social-emotional stuff in here too Yeah. It wasn't even considered as part of ADHD at the time. Yep. And I was just like, "Oh, yeah, of course they wouldn't have anything about that because…" Yep, yeah. I was reading the latest copy of the DSM this week, as I do, and, um, and it, um, it was funny to even see in that it's like it's an addendum.

14:46It's kind of put in the corner. Like also side note, emotional regulation is a thing with ADHD Yeah. It's like it's hard to measure, so we don't really want to Okay. Do you wanna take us through what they found? yeah, so they, they found the middle school was associated with a significant disruption, um, with, Am I reading my note right? It says decline of inattention, hyperactivity, impulsivity. But yes, this is why. So this was an int- what I thought was really interesting is that, uh, teacher results did not show vastly different results for their, uh, ADHD symptoms, but parent surveys showed increased, uh, ADHD symptoms, which for me, I read that as this is a lot of masking going on at school now, and they're just letting loose once they get home Yeah, 100%.

15:39It didn't necessarily feel like that's what they were getting from it, but it was, it was interesting. Like, the, I, I had the exact same thought Yeah. Yeah, it was def-- yeah, it was, uh, 'cause yeah, that was my, note. Like, mm, they did not… I 'Cause they were like, "Oh yeah, this is probably 'cause, uh, they have different teachers, and the different teachers are rating them differently." And I'm like, I think it's just 'cause when you, uh, I mean, you're probably not as comfortable with five different teachers as you are with one teacher.

16:10and so there's gonna be an increased level of, needing to keep up your defenses while you're at school and not let your try and, overcompensate for your ADHD symptoms Yeah. And we see that. We, we talk about that. You know, people talk about masking and, and people having, you know, sort of falling apart once they get home, um, when they're in those environments. Um, but yeah, it was, it was an interesting, you know, I guess if, if you were to say, um, well, why we're talking about this paper as well as the other paper, what would you kind of say is the reason?

16:42what I really saw was for the original MTA research, it really, it showed like this You know, the level of impairment, you know, staying, uh, the same when, uh, or, uh, increasing after the eight years because the treatment's no longer effective. But I real- like, there is so m- it's saying like, hey look, there is so much more than just saying eight years passed. You are going through puberty, you're going through middle school, you're going through, uh, big life changes and changes in how, uh, the demands on you.

17:16Like, the demands on an elementary school student versus the demand, demands on a middle school student or a high school student are vastly different. and so just saying the initial treatment didn't hold up, I feel doesn't do service for looking at how our life changes. 'Cause it's, my life demand changes and my, and the effectiveness of my medication vastly changes. And different demands in your life demand different strategies. And so when you're not learning new strategies, it's going, it's not gonna be as effective Yeah.

17:59No, exactly. Exactly, and I think that's the, that's the reality. Otherwise, you could say, you know, ooh, somewhere between 2020, you know, and 2024, like, everybody just randomly got worse. Their ADHD didn't do as well, and it's like, no, there was something else that happened to all of those people Yeah, I am, I am so amazed how many people completely ignore stuff with the pandemic when talking about, they're like, "Man, kids just are having more trouble in school nowadays.

18:32Who knows why?" And I'm like, "There is data. Yeah. There is, there's something happened, Mm-hmm. and we know what happened, and pretending like that didn't happen does not help answer the question." Yeah. Yeah, I get that question a lot, um, in interviews, which is why it comes up a lot. It's like, "What happened?" And I'm like, "Well, everyone had to suddenly change everything about their life." And middle school is a similar thing Yeah, absolutely.

18:57It's you, uh, might not have the same friends. You're gonna have a different workload. You're gonna have a bunch of teachers. So, and I, I feel like middle school teachers are a little bit tougher, uh, than elementary school. Somet- you know what? I'm gonna take that back. I'm g- I'm gonna 100% take that back because I've met some middle, elementary school teachers that are just as tough. Uh, but I feel like there is… You're gonna have a different relationship with your teachers in middle school versus elementary school, and sometimes that's gonna be for the better, and sometimes you're gonna be like, "Man My spi-- history teacher is just out to get me and I can't do anything about it.

19:35yeah. gosh, that takes me back. although, i, for me, yeah, a primary school teacher, there was a really scary primary school teacher. nobody wanted to be in her class Yeah, I, I think with my kids and, like, how much they love their teachers, and I'm like, "I wonder if that's gonna continue as they get to, like, get into these, like, you know, where you can choose your teachers more based on classes and Yeah. Yeah, definitely. And I think that was an interesting conversation, 'cause they, they came into it saying, "I wonder if environment has an effect," basically.

20:07This was the conversation, was like, "Okay, we've talked about mult- m- you know, multi- multiple different kinds of treatments. Um, you know, we've talked about age and, and how that can have an effect on ADHD. What about environment? Environment has a big effect." And then they found, they were like, "Well, the teachers didn't really notice it," but the parents definitely did Yeah. And I think there's, ag- again, I think it's worth mentioning, you know, these are, while these studies came out in 2008, 2009, and I'd like to think that wasn't that long ago, terms of research, that's, that's old research Yeah.

20:43Like, th- so while these were, like, very influential in how we think about ADHD now, at the time it was just like, "Oh yeah," like, this is really building that foundation of what we know about ADHD Hello everyone. If you have enjoyed listening to this episode, then you might like to listen to my podcast, the ADHD Skills Lab, where we go and deep dive into more of the research, and also we focus on ADHD support for business owners, whether you're aspiring or you have your own company.

21:20Um, and if you have your own company and you wish that you had somebody who would just build these systems for you so you could stop figuring out what to do all the time, well, that's what we do. We are mentor and operator together. So if you wanna learn a little bit more about that, you can find me at Unconventional Organization. Thanks for listening.