ADHD as a fluctuating condition

By Peik Gustafsson

Short comment
The authors challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Few studies have studied remission, recurrence, and recovery. Many studies have only given single-time snapshots with a definition of remission as “failing to meet DSM criteria” without reference to subtype of ADHD or patterns of remission. Biederman’s study (Biederman J, Petty CR, Evans M, et al., 2010) showed that 65-67 % of the children followed up 10 years later (mean age 22 years) no longer fulfilled ADHD criteria, but 77-78% of these had remaining ADHD symptoms, impairment and/or treatment for ADHD. The number of fully remitted individuals in this study was 22-23%. Thus, earlier studies have indicated a tendency of ADHD to be fluctuating between full remission, partial remission, and persistence.

The present article is based on data from the Multimodal Treatment study of ADHD. Data on symptoms, impairments, comorbid conditions, and treatment utilization have been collected from multiple informants (parents, teachers, and patients). Longitudinal patterns during the 16-year follow-up period from baseline have been described in this prospective follow-up study. Of the study participants 95.3% (558 patients) had data from at least one follow-up. Child and adolescent symptoms of ADHD were recorded with the Swanson, Nolan, and Pelham rating scale, completed by parents, teachers, and adolescents and symptoms in adulthood were recorded with the Conners’ Adult ADHD Rating Scale, completed by participants and parents. Impairment in childhood and adolescence was rated with the Columbia Impairment Scale (parent report) and in adulthood with the Impairment Rating Scale (parent and self-report). Comorbid conditions were recorded with the Diagnostic Interview Schedule for Children (parent and self-report). Service utilization was recorded by using the Services for Children and Adolescents– Parent Interview.

The study shows that 1/3 of the patients had full- remission at some point, but that 60% of these remitted patients later experienced a partial or full recurrence of ADHD. The recovery rate for the whole period was 9.1%, and the rate of persistence was 10.8%. Most of the patients (63.8%) showed a fluctuating pattern of persistence and remission. At any given follow-up 40-50% of the participants met DSM- criteria for ADHD.

This study is of great interest since it shows a fluctuating pattern of ADHD-symptom for most of the patients with ADHD of combined type, which has not been well studied and described until now. Environmental factors could be of great importance in triggering periods of recurrence. Individuals with ADHD should be followed over time even when there are signs of remission. Further knowledge of factors that can trigger a recurrence and factors that can trigger a remission could be of great value for establishing prevention programs for children, adolescents, and adults with ADHD.

Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD – PubMed (

Sibley MH, Arnold LE, Swanson JM, Hechtman LT, Kennedy TM, Owens E, Molina BSG, Jensen PS, Hinshaw SP, Roy A, Chronis-Tuscano A, Newcorn JH, Rohde LA; MTA Cooperative Group. Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. 2021 Aug 13:appiajp202121010032. doi: 10.1176/appi.ajp.2021.21010032. Epub ahead of print. PMID: 34384227.


Objective: It is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood.

Methods: Children with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing.

Results: Approximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time.

Conclusions: The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.

Keywords: ADHD; Neurodevelopmental Disorders; Remission; Symptoms; Treatment.