Most patients will not make a full recovery from attention-deficit/hyperactivity disorder in adulthood. This late-breaking finding headlined the World Congress on ADHD – Virtual Event. Held under the specter of SARS-CoV-2, the virtual program delved into the latest research on ADHD pathophysiology, imaging, genetics, and issues on medical and psychiatric comorbidities.
Dr. Margaret H. Sibley
However, one of the conference’s highlights was a piece of unpublished work on remission patterns by Margaret Sibley, PhD, associate professor of psychiatry and behavioral sciences at the University of Washington, Seattle.
Anywhere from 65% to 67% of young adults have desistant ADHD – meaning that they no longer meet criteria. Only up to 23% experience full remission, said Dr. Sibley during a special late-breaking session. All research on remission and most on persistence consider just one endpoint – nothing is known about longitudinal fluctuations in remission status over time.
Her research sought to answer a key question: Do people fully recover from ADHD?
Using data from the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study, Dr. Sibley prospectively followed over 550 children aged 7-9.9 years with DSM-IV combined-type ADHD over 14 years, until 16 years after baseline, using interviews, questionnaires, and rating scales to track symptoms, impairment, and treatment history.
The researchers also came up with a “winning” definition for full remission, which included three or fewer symptoms of inattention and hyperactive impulsivity from all available reporters, negligible ADHD-related impairment based on preestablished impairment rating thresholds, and discontinuation of medication and behavioral treatments for at least a month prior to assessment.
In the longitudinal results, Dr. Sibley and colleagues reported that the majority (63.8%) demonstrated fluctuations between full or partial remission and ADHD recurrence. Only 9.1% sustained full remission over the course of the study. From these findings, ADHD appears to be a fluctuating disorder. While it continues into adulthood for most people, there may also be periods of remission or “good functioning.”
Most desistance from ADHD represents partial, not full remission, said Dr. Sibley. The results also show that recovery by young adulthood is very rare – most patients with remitted ADHD have recurrences.
These are important findings, said Luis Augusto Rohde, MD, PhD, who co-organized the congress’ scientific program committee with Manfred Gerlach, PhD. It shows that a patient’s ADHD may sometimes be more definitive and at other times, no clear phenotype expression emerges.
COVID’s influence
COVID-19 greatly influenced this year’s program’s agenda, said Dr. Rohde. “There’s a lot of evidence that ADHD patients are at greater risk for COVID-19, which is not a surprise,” said Dr. Rohde, professor of child and adolescent psychiatry at the Federal University of Rio Grande do Sul’s department of psychiatry in Porto Alegre, Brazil.
ADHD is a combination of genetic liability and the demands of the environment. “In times like we are living in right now, if you have increasing demands and stress from the environment, you trigger symptoms in those even with lower genetic liability,” he said. ADHD’s pathophysiology involves attention and executive deficit disorder, which means these patients may not follow strategies to avoid infection.
This shows why COVID was so important to the discussion of program topics, he said.
Two experts addressed this subject head on in a point-counterpoint debate, “Residual effects of the 2019 pandemic will mirror the 1918 pandemic: Will we have lots of new ADHD cases?” James Swanson, PhD, professor of pediatrics at the University of California, Irvine, projected that biological coeffects of COVID-19 will lead to ADHD symptoms, generating potentially 5 million new ADHD cases.
David Coghill, MBChB, MD, a professor of child adolescent mental health at the University of Melbourne, countered that not enough data are available yet to back this hypothesis. “Researchers are asking this question, but clinically we don’t know enough.”
While the COVID virus might not directly lead to more cases of ADHD, this could potentially happen indirectly through environmental agents of the pandemic, offered Dr. Rohde. “We’ve clearly seen in our appointments with families and children that they can’t face the amount of schooling and working from home,” he said.